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2.5 Heart Failure

First line drugs Second line drugs Specialist drugs Secondary care drugs

Traffic light status (TLS) explained:

  • Green: Routine prescribing within licensed indication
  • Amber 1: specialist recommendation followed by GP initiation and continuation
  • Amber 2: specialist or GP initiation in line with local guideline after 1st line failure followed by GP continuation
  • Amber 3: specialist initiation and stabilisation followed by GP continuation
  • Amber SCG: specialist initiation and stabilisation followed by GP continuation in line with an agreed shared care guideline
  • Red: Hospital or specialist prescribing only

 

 

Aldosterone Antagonists

Eplerenone (Amber 2)

  • Tablets 25mg, 50mg

Notes:

  • For use with standard therapy, to reduce risk of cardiovascular mortality and morbidity in stable patients with LVD (LVEF ≤40%) and clinical evidence of heart failure after recent MI or in patients with LVD (LVEF ≤30%) and chronic heart failure (NYHA II).
  • Therapy should be started within 3-14 days of event.
  • Eplerenone may be useful when patients have symptomatic gynaecomastia.
  • Plasma potassium levels should be checked before eplerenone is started, during the first week of treatment, and a month after starting. It is expected that treatment will be commenced within PHNT. GPs will then be asked to review potassium levels after one month of treatment and adjust the dose according to the table below:

 

Serum Potassium(mmol/L)

Action

Dose adjustment

< 5

Increase

25mg alternate days to 25mg OD

 

25mg OD to 50mg OD

 

5.0 – 5.4

 

Maintain

No dose adjustment

5.5 – 5.9

Decrease

50mg OD to 25mg OD

 

25mg OD to 25mg alternate days

 

25mg alternate days to withhold

≥6.0

Withold

N/A

 

  • Serum potassium should be assessed as needed periodically thereafter.

 

  • Elderly patients, diabetics, those with mild renal failure or mild to moderate hepatic failure should be monitored more frequently to ensure that normal potassium levels are maintained.

 

Spironolactone

  • Tablets 25mg, 50mg, 100mg
  • Oral Suspension 5mg/5mL, 10mg/5mL, 25mg/5mL, 50mg/5mL and 100mg/5mL

Notes:

  • Routine co-prescribing of potassium sparing diuretics in combination with thiazide or loop diuretics should be avoided except in patients where hypokalaemia has been demonstrated or in patients not taking an ACE inhibitor who are at risk from hypokalaemia e.g. those with severe CHD and arrhythmias and those taking digoxin.
  • In severe heart failure, spironolactone added to other treatments in a low dose (e.g. 25mg daily) can reduce mortality and morbidity. Careful monitoring for hyperkalaemia and hypovolaemia is required especially for people taking other diuretics and/or ACE inhibitors.
  • Spironolactone has been shown to be carcinogenic in rodents. As a result the CSM has restricted its license to its use in oedema and ascites in cirrhosis of the liver, malignant ascites, congested cardiac failure, nephrotic syndrome and primary hyperaldosteronism.

 

Phosphodiesterase type-3 inhibitors

Milrinone

  • Injection 1mg/mL (10mL amp) 

 

 

 

  

Traffic light status (TLS) explained:

  • Green: Routine prescribing within licensed indication
  • Amber 1: specialist recommendation followed by GP initiation and continuation
  • Amber 2: specialist or GP initiation in line with local guideline after 1st line failure followed by GP continuation
  • Amber 3: specialist initiation and stabilisation followed by GP continuation
  • Amber SCG: specialist initiation and stabilisation followed by GP continuation in line with an agreed shared care guideline
  • Red: Hospital or specialist prescribing only

 

Return to Chapter: 2. Cardiovascular system

Last updated by: Dupe Fagbenro on 14-11-2018 14:56